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Health Questionnaire
Please fill out the following Questionnaire before attending your first class (you can also download a
PDF version of the form here
):
*
Indicates required field
Name
*
First
Last
Email
*
Address
*
Phone Number
*
Do you have, any physical conditions or injuries that your instructor should know about?
*
Yes
No
Do you have a tendency to lose consciousness or fall over as a result of dizziness?
*
Yes
No
Are you on any medication?
*
Yes
No
Do you have issues with your bones or joints?
*
Yes
No
Do you have a cardiac condition?
*
Yes
No
Are you pregnant or have you had a baby in the last 12 months?
*
Yes
No
Do you have uncontrolled high or low pressure?
*
Yes
No
Do you have any eye, ear or throat issues?
*
Yes
No
Do you have varicose veins?
*
Yes
No
Have you had any operations?
*
Yes
No
Do you have any type of hernia or prolapse?
*
Yes
No
Do you suffer any form of menstrual disorder?
*
Yes
No
Do you have any allergies?
*
Yes
No
If you answered yes to any of the above please give further details:
*
I agree to receiving marketing and promotional materials
*
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